Practice Address
September 20, 2011
No Pay Insurance
Att: Appeals Supervisor
555 No Pay Way, Suite Zero
Cheap, AZ 55555
Patient: Jane Doe
ID: 555-55-5555
DOS: 05/05/2003
Appeals Supervisor:
I am hereby appealing your decision to deny payment for 94002 and/or 96004 (Dynamic Surface EMG testing with report.
At the initial examination of (patient name), I followed the protocols explicitly identified by the Health Care Financing Administration’s guidelines for evaluation and management of the musculoskeletal system. The evaluation and management visit was the first visit in which I encountered the patient. As part of this visit, I took a thorough history and visually examined the patient’s range of motion and denoted if (patient name) experienced pain with each plane of motion.
In addition, as per the HCFA regulations, I subjectively tested the patient’s muscle strength in order to determine if (patient’s name) had neuromotor deficit. These two procedures are indeed part of the E & M evaluation and were included in the CPT code 99203(4). On the next visit, I performed a computerized range of motion combined with Dynamic SEMG using dual inclinometers . This is the recommended procedure from the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition (specifically, the AMA’s “Practical Guide to Range of Motion Assessment”, copyright 2009 which shows the combination of Range of Motion combined with Dynamic Surface EMG as a test which improves sensitivity and specificity of Range of Motion testing (Geitzman, 2005). This procedure was performed in order to quantify the patient’s range of motion limitation and/or asymmetry of motion in addition to muscular guarding as a measure in addition to Range of Motion for the purpose described by the AMA in the CPT code 96004. By performing this type of specific and accurate test, we are able to effectively monitor the patient’s progress or regress and determine if treatment is necessary and effective.
These tests are performed in a sincere effort to quantitatively and objectively examine the patient and document improvement. This helps me, the doctor, manage the care for the patient more effectively.
To summarize, the visual range of motion and subjective manual muscle testing are included in and are part of the main procedure on the initial evaluation and management visit. The computerized range of motion and Dynamic Surface EMG are separate and distinct tests and are accompanied by the necessary reports, done on the same or separate days, and each have their own CPT code, which was used appropriately.
With regards to the question you had regarding the playing of music: This question specifically applies to the use of Surface EMG for Biofeedback muscle relaxation training (CPT CODE 90901) which was not performed, and thus does not apply. This in general applies to resting level measurements. We were measuring muscle activity in motion, thus making the resting level SEMG measurement questions irrelevant.
We are not performing resting level measurements of Surface EMG, where these factors may affect Surface EMG. Instead we are measuring muscle activity in motion. The very high levels of muscle activity required to produce human motion overshadow so significantly any affect of room termperature, skin temperature, room temperature, surface contact of the electrodes etc. The effect of these factors may affect the use of Surface EMG when used for Biofeedback, and specifically for muscle relaxation training. We are not in any way performing such tests, and therefore these variables are irrelevant and have no effect.”
Sincerely,
Doctor Name, Title